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Precholecystectomy

  • In a few patients (mostly women) with biliary pain, conventional radiographic studies of the upper GI tract and gallbladder, including cholangiography, are unremarkable

    • However, emptying of the gallbladder is markedly reduced on gallbladder scintigraphy after injection of cholecystokinin

    • Similar symptoms may also be caused by sphincter of Oddi dysfunction

Postcholecystectomy

  • Continued complaints of right upper quadrant pain, flatulence, and fatty food intolerance

  • Pain has been associated with

    • Choledocholithiasis

    • Bile duct stricture

    • Dilation of the cystic duct remnant

    • Neuroma formation in the ductal wall

    • Foreign body granuloma

    • Anterior cutaneous nerve entrapment syndrome

    • Traction on the bile duct by a long cystic duct

Diagnosis

  • Endoscopic ultrasonography or retrograde cholangiography may be necessary to demonstrate a stone or stricture

  • Patients with elevated liver enzymes or amylase (twofold) and a dilated bile duct (> 12 mm) can be assumed to have sphincter stenosis

  • For those patients without all the features of sphincter stenosis, biliary manometry may be performed to document elevated baseline sphincter of Oddi pressures typical of sphincter dysfunction

  • Biliary scintigraphy after intravenous administration of morphine and magnetic resonance cholangiopancreatography following intravenous secretin show promise as screening tests for sphincter dysfunction

Treatment

  • Precholecystectomy syndrome: cholecystectomy is often curative

  • Postcholecystectomy syndrome

    • Endoscopic sphincterotomy is most likely to relieve symptoms in patients with a sphincter disorder or stenosis

    • A calcium channel blocker, long-acting nitrate, phosphodiesterase inhibitor (eg, vardenafil), or possibly injection of the sphincter with botulinum toxin may be beneficial in some cases

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